stress

decision making
alcohol and other drugs
error management
teamwork
communication
leadership
fatigue
human performance
The single biggest problem in communication
is the illusion that it has taken place.
George Bernard Shaw, Irish dramatist
Chapter 8
COMMUNICATION
Regardless of whether you work in a one-person
operation or a large organisation, effective
communication is a critical part of maintenance
work. Misunderstandings and communication
failures cost money, and at worst, can compromise
safety. Clear communication can be the difference
between getting a job right the rst time, or
expensive re-work; doing the job safely, or injury to
maintenance personnel; and of course, safe ight or
aircraft accidents.
Barriers to effective communication
in aviation maintenance 128
Managing communication 128
Why does communication fail in
aviation maintenance? 133
Managing task handover, pre-task briengs
and task changes 137
Tips for improving communication
and avoiding errors 142
Key points 143
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Barriers to effective communication in aviation
maintenance
Communication problems are at the heart of many coordination breakdowns in maintenance, as the
following example illustrates:
Two of us were dispatching the aircraft. The nose steering bypass pin was left
in. The aircraft began to taxi, but stopped as soon as no steering recognised.
We removed pin and ops normal. This is a repetitive maintenance task; both of
us assumed the other had the pin.
Anonymous report
We often think communication is easy. After all, we do it all the time. Yet everyday communication
is not as simple as it seems, and there is room for most of us to improve our communication skills.
When maintenance supervisors in the U.S. were asked to name the most important skill needed to be
effective in their current position, half mentioned people skills and communication. Many of them also
said this was the part of the job they were least prepared for.
Managing communication
Communication can be dened as achieving shared meaning, and to be effective, requires four elements
working together.
The individual sending the message must present that message clearly, with the necessary detail, and
should have credibility.
The person receiving the message must be prepared to, and decide to, listen; ask questions if they dont
understand something; and trust the person sending the message.
The delivery method chosen must suit the circumstances and needs of both sender and receiver.
The content of the message has to resonate and connect, on some level, with the already-held beliefs of
the receiver.
If communication is to be effective, therefore, it has to be worked upon, and rened.
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Communication channels
When we think of communication, we tend to think rst of oral/spoken communication, but in the
maintenance environment, as elsewhere, communication takes place via several channels, not just the
spoken word.
Maintenance is heavily reliant on documentation for information transfer; for example, logbooks,
maintenance manuals and parts catalogues. However, important information is also transferred via other
means, over the phone, via face-to-face communication, and even through body language and other
non-verbal cues. Communication in maintenance also occurs via physical cues such as the placement of
tools and parts and the location of ground servicing equipment, tags or lockout devices. In some cases we
consciously transmit or seek information, such as signing off a logbook entry, or referring to a maintenance
manual. In other cases, however, we are still sending or receiving information without necessarily being
aware that communication is occurring.
The main communication channels in maintenance can be summarised as oralspeech; written
documentation; non-verbal (wordless) cues; and physical cues.
Speech
Speaking is the most natural form of communication, yet oral communication is often far from perfect.
The error rate for oral communication in industrial settings is estimated to be around 3 per cent
32
. In other
words, approximately one out of every 30 spoken exchanges in workplaces involves a misunderstanding!
In aviation, such communication errors can be catastrophic.
In 1989, a 747 freighter crashed into terrain when air trafc control told the pilot to descend two four zero
zero, meaning 2400ft, but the pilot interpreted this as an instruction to descend to 400ft. Whenever oral
communication occurs in maintenance, those conveying the message need to make sure the message has
been understood, and those receiving it must listen, conrm that they have received the message, and ask
questions if they have any doubts.
Documents
Maintenance is driven by paperwork, and communicating via documentation is such a part of the job many
LAMEs spend more time wielding a pen than they do a spanner or a screwdriver. Communication via written
material usually means there are few opportunities to clarify or query the message once it is sent. This is a
particular issue with pilot write-ups, a topic that will be dealt with later in this section.
In the English language, many words can have more than one meaning. Generally, this is a strength for the
richness of the language, but for aviation maintenance, a potential problem. For example, in everyday English
the word tap has several different meanings, including: a tap above a sink, the action of removing uid from
something, to listen in on a telephone conversation, or to hit/strike gently.
The European Association of Aerospace Industries
33
has developed a form of simplied English to create
brief and unambiguous text for aerospace manuals, and both Boeing and Airbus are now using the system.
Simplied English limits the number of words used to describe steps and also ensures that each word only
has one meaning. In simplied English, tap has the meaning only of to hit something, as in tap with a
hammer. Information on simplied English is available at www.aecma.org
32
Kirwan, B. (1994). A practical guide to human reliability assessment. London: Taylor and Francis.
33
AECMA (1989). A guide for the preparation of aircraft maintenance documentation in the international
aerospace maintenance language. Paris: Association Europenne des Consructeurs de Matriel Aerospatial.
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Non-verbal communication
Non-verbal communication is important in maintenance, particularly in situations where speech cannot
be used, such as in noisy environments, or where people are wearing hearing protection. Non-verbal cues
include gestures, facial expressions, tone of voice, and body language. If you see a colleague walking in
the direction of an aircraft carrying a toolbox, it probably sends you a message about their intentions, but of
course it is possible to misinterpret such messages.
Particularly under time pressure or stress, we may see or hear what we expect, rather than what is actually
there. The following maintenance incident illustrates the problem of misinterpreted body language.
The aircraft ight manual and pilots operations manual, which were removed
from the aircraft earlier, were on a table inside the hangar. The pilot placed
his hand on the two manuals on the table noting that they were, or had been,
looked at. After a few minutes I went back into the hangar where I saw the
cabin door being closed and latched by one of the crew from the inside.
I recall looking over at the table and seeing the manuals not there any more,
suggesting the crew had taken them with them. Just after that I noticed them
on a chair.
ASRS Report
Physical cues
Maintenance also relies on physical cues to communicate information between maintenance personnel and
to pilots.Some objects such as placards, tags or streamers attached to lock-out pins have been designed
specically to communicate information.
Information is also communicated by informal cues. An open cowl, or the position of a work stand,
might send a message that maintenance is underway, but sometimes the message does not get through,
or we do not realise that people have come to rely on these informal cues for communication. In the
following example, a chain of communication issues nearly led to an unserviceable aircraft being operated.
The example involves two communication channelsrst the failure to use appropriate documentation,
and second an unintended message sent by the apparent physical state of the aircraft.
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Aircraft arrived on Friday midday, and no time was stated when it had to be
serviceable by. A job was started on an engine magneto with oral instructions,
but not written in the maintenance release. At 5.00pm, no one had asked for
the aircraft to be completed, so the cowls were tted and the aircraft placed
outside without the maintenance being nished. On Sunday, I was at the airport
and a pilot was doing a daily check before departure. I was able to nish the
timing and ret the cowls and sign for the job. The aircraft could have been
operated unserviceable.
(LAME, respondent 315)
What communication failures occurred in this example?
Sender Receiver
Feedback
to create shared meaning
C
A
B
Message
received
Message
sent
The gure above presents a simple model of communication. The diagram shows the message sent by the
sender (A) and the message from the point of view of the receiver (C). The overlapping area (B) represents
effective communication. The process of communication occurs in a context of noise, which means not
only unwanted sound, but also other impediments to communication such as unclear speech, time pressure
or distraction. The relative size of the areas in this diagram is for illustrative purposes only. We would hope
that in your workplace effective communication is much more extensive than shown in the diagram! The
diagram also shows that, in many cases, there is a potential for useful feedback from the receiver to the
sender, as the receiver claries the message.
A model of communication
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Communication errors can take several forms:
Errors by sender
Message not sentsender has a hidden agenda, and keeps information to themselves
Incomplete or ambiguous message sentsender uses inappropriate method (message left on phone,
face-to-face communication not used for important/sensitive messages)
Inconsistency between oral and non-verbal cuessenders attitude/body language does not reinforce
an urgent, safety-critical message.
Errors by sender and receiver
Failure to reach clear understandingshared meaning
Wrong mode used (e.g. oral message when documentation required, or email sent assuming it would
be read).
Errors by receiver
Message not received
Message understood incorrectly
Message not claried when necessary.
It is worth asking why these errors occur. For example: why would a sender not send a message?
Or why would a receiver interpret a message differently from the sender? Some of the reasons for
these communication breakdowns follow.
Rolls-Royce plc 2013
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Why does communication fail in aviation
maintenance?
Failure to verbalise decisions a sender may decide to keep their plans to themselves, sometimes referred
to as having a hidden agenda.
Cultural barrier to speaking up a sender may fail to communicate because of a perceived barrier to
communication, particularly between professional groups such as LAMES and pilots. The example below
reected a barrier between avionics, engine and airframe disciplines.
An airframe and engine tradesman did not properly secure an oil line. I did not
say anything, though I seem to remember noticing, as electrical instrument
LAMEs comments on engine airframe systems are unwelcome/unheeded.
Incident report

Lack of assertiveness Assertive communication is direct and open, without being either aggressive or
excessively polite. Assertiveness is a skill all maintenance engineers can develop. In the mid-1990s, a
747-300 landed with the nose wheel retracted. After the main wheels had touched down, and reverse
thrust had been selected, the captain briey considered applying power for a go-around. The ight engineer
recognised that this would be unsafe and assertively stated No, you wont, which alerted the pilots that
they were now committed to continuing with the landing.
The following incident could have been prevented by just a small degree of assertiveness.
While investigating a report of vibration near the left-hand over wing escape
exit on an A319, my lead decided to check the hatch seals. He asked me to
open the hatch. I believed that this aircraft had a slide, but due to noise and
the approaching departure time, I opened the hatch as requested. The slide
deployed as designed. If I had been more assertive and communicated my
belief that the lead was incorrect, this incident could have been prevented.
ASRS report
Passive listening A receiver who does not repeat, (or paraphrase) the message cannot be sure that they
have completely understood it. If you phone through a delivery order to the local pizza parlour, chances are
they will read back your order to conrm they have got it right. Yet a basic read-back such as this is often
skipped in safety-critical workplaces such as hospitals and aircraft hangars, despite the potentially serious
consequences of communication errors.
Expectancy errors Our expectations set the context for communication and inuence the messages we
receive. If you expect you are about to be told about an oil leak, but are told about a fuel leak instead, you
may unconsciously continue to think about an oil leak. The following example shows how context can
inuence how we interpret a piece of information.
What do you see in the box on each line below? In fact, the symbols are exactly the same, but in each case
the context leads us to see the symbols as either B or the number 13.
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Inappropriate non-verbal cues If a colleague warned you that there was a re in the building, but told you
in a relaxed voice, and were making no apparent effort to do anything about it, you might assume that you
had misheard them. Perhaps they were asking to borrow a le, or were telling you about a news story on TV.
When there is a disconnect between non-verbal cues (such as tone of voice and facial expression) and the
content of a message, we sometimes pay more attention to the non-verbal part of the message.
In maintenance operations, critical information is sometimes communicated without the necessary
dramatic emphasis.
stress
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error management
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leadership
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Satellite worth $500 million dropped due to communication error
An aircraft falling off jacks is bad enough, but what if you dropped a satellite worth $500 million?
In 2003, a weather satellite known as NOAA-N Prime was dropped from a work stand during
pre-launch preparations in California. The satellite fell about a metre to the ground while it was
being turned from a vertical to a horizontal position.
Work stands at the facility were shared between two different satellite projects, and were kept in
a storeroom when not being used. A couple of weeks before the accident, workers from the other
satellite program had decided to use the work stand because their own stand was red-tagged with
a problem. They went to the storeroom and began to prepare the stand by removing 24 bolts that
held the special adaptor plate for the weather satellite, so they could t an adaptor plate for their own
satellite. After they had removed the bolts however, they decided it would be easier to repair their
own stand, and use it to work on their satellite.
The stand in the storeroom was then left with its adaptor plate in place, but not connected by
any bolts. There was no requirement to attach a red tag to the stand as it was understood that all
personnel had a responsibility to verify that ground service equipment (GSE) was properly set up
for use.
Two weeks later, the weather satellite needed to be attached to a work stand and rotated to a
horizontal position to enable a piece of onboard equipment to be replaced. Almost all crew members
said that they thought this was just another routine operation. The supervisor was required to
conduct a pre-task brieng to make sure that all team members understood their roles, potential
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Dropped satellite. Source of image: NOAA N-PRIME Mishap Investigation, Final Report.
September 13, 2004. National Aeronautics and Space Administration.
problems had been identied, and the equipment was set up correctly. After the accident, some team
members said that a pre-task brieng had been held, others did not remember a brieng.
The work stand was retrieved from the storeroom and the weather satellite was bolted to the adaptor
plate, but the fact that the adaptor plate was not bolted to the work stand was overlooked.
The engineer in charge was required to check that the work stand was in the correct conguration
through a visual and physical check, but instead he referred to paperwork from a previous operation
to conrm that the stand was ready to rotate the satellite. Finally, the lead technician and an
inspector signed the paperwork to verify that the satellite was ready to be rotated, without personally
conducting or witnessing the operation.
Shortly before the satellite was rotated, one member of the team was overheard to remark that
there were empty bolt holes on the work stand, but no one seems to have paid any attention to the
comment. In general at this organisation, there was a strong reluctance to speak up and hold up an
operation unless an individual was absolutely sure something was wrong.
The crew then began to rotate the satellite, but as it reached 13 degrees of tilt from the vertical,
it slipped off the work stand and fell approximately a metre to the oor, tipping over in the process.
Fortunately, nobody was injured.
The satellite was nally repaired (at a cost of $217 million) and was launched in 2009.
What communication problems do you think led to this accident?
Do any of these communication issues exist in your workplace? Which ones?
What could have been done to prevent the accident?
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Communication with ight crew
There is often room to improve communication between pilots and maintenance personnel. In a recent study,
pilots and maintenance personnel on two U.S. air carriers were asked about their use of the aircraft logbook.
The results indicated a distinct split between the two groups.
Maintenance engineers frequently wanted more information from pilots logbook entries, yet pilots were
generally satised with the level of detail in maintenance write-ups. A common complaint from the
maintenance personnel was that pilots made logbook entries in which a component was simply described
as INOP (inoperative) with no further details. Of interest was that pilots reported that they made logbook
entries primarily to give information to maintenance personnel. Maintenance personnel, on the other hand,
considered that their logbook sign-offs were made primarily for the regulator.
34

The following incident report dealt with coordination between engineering personnel and ight crew.
Difculties with refuelling the aircraft had made us late. The captain was
buzzing on the ground call while we were doing nal checks; he interrupted the
nal walk-around inspection twice to ask us how much longer. The forward
hatch was opened on transits on hot days to cool the electrical equipment.
But this procedure is not used often, and this was not a hot day. We were not
aware that the forward hatch had been opened and the warning light in the
cockpit was unserviceable. This was in the log, but we didnt have access to
the log and the problem had not been communicated to us. The aircraft failed
to pressurise after departure, had to dump fuel and return to blocks. This
happened earlier in my career. At the time we were young and nave, didnt
have the necessary skills to manage our time. Had too much respect for the
captains authority.
Anonymous report
What communication failures occurred in this example?
34
Munro, P., Kanki, B. and Jordan, K. (2008). Beyond INOP: logbook communication between airline
mechanics and pilots. International Journal
Rolls-Royce plc
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Managing task handover, pre-task briengs
and task changes
Task briengs
Task briengs can help to make sure all members of a team are ready to work together. Pre-task briengs are
standard practice for surgeons and pilots, and should be for maintenance personnel as well.
Pre-task brieng
What is the objective of the task?
How will it be carried out?
What equipment will be used?
Does each person have a clearly assigned role?
What could go wrongwhat are the risks?
Brieng during the task where necessary
Critique and update existing plans
Evaluate results of previous decisions
Inform crew of changes in task.
Post-task debrief
Critique entire task
Give all crew a chance to comment
Feedback to crewmembers
Identify areas for improvement.
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stress
decision making
alcohol and other drugs
error management
teamwork
communication
leadership
fatigue
human performance
An accident related to a shift handover
In 1991, an Embraer 120 experienced a structural breakup in ight and crashed near Eagle Lake,
Texas, resulting in 14 fatalities. The night before the accident, the aircraft had been scheduled to
have the de-ice boots replaced on the left and right horizontal stabilisers. The work was started by
the evening shift, and was going to be completed by the midnight shift. Two supervisors were on
evening shift that night; one was supervising the work on the accident aircraft, while the other was
overseeing a C-check on another aircraft. The aircraft scheduled for the de-ice boot change was
brought into the hangar at around 21.30 by the evening shift. Two mechanics and a quality control
inspector then used a hydraulic lift platform to get access to the aircrafts T tail, which is about 20
feet above the ground. (Under the U.S. system, inspectors oversee the work of mechanics [LAMEs]
but they are not usually expected to assist mechanics with tasks.) The mechanics started removing
the screws that attached the leading edge/de-ice boot assembly to the underside of the left horizontal
stabiliser, but were slowed down by some stripped screws. Meanwhile, the inspector removed the
attaching screws from the top of the left horizontal stabiliser, and then moved across to the right side
and removed those screws as well, anticipating that both de-ice boots would be changed that night,
as planned.
The hangar supervisor for the midnight shift arrived early for work and saw the evening shift
mechanics working on the right de-ice boot. The supervisor checked the evening shift inspectors
turnover form and found no write-up on the aircraftthe inspector who had removed the upper
screws had not yet made his log entries. The midnight shift supervisor then asked one of the evening
shift supervisors (who had been working on the C-check) whether work had started on the left de-ice
boot. The evening shift supervisor looked up at the tail where the mechanics were working and said
no. The midnight shift supervisor decided that the work on the left hand replacement boot would
have to wait for another night.
Shift handovers
A critical area of maintenance communication is the shift handover. Even if you work alone or in a small
team, there will still be times when a task is left partially completed, and either handed to another engineer,
or resumed by you later. Studies have found that some of the most serious maintenance errors have resulted
from communication problems during handovers.
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At 22.30, the inspector who had removed the upper screws from the leading edges of both
stabilisers lled out a turnover form with the entry, helped the mechanic remove the de-ice boots.
He then clocked out and went home. Later, the inspector stated that he had placed the screws he had
removed from leading edges of the stabiliser in a bag and had placed the bag on the hydraulic lift.
As the evening shift prepared to go home, one of the mechanics (M1) who had removed the screws
from the underside of the left horizontal stabiliser gave a verbal handover brieng to an arriving
mechanic (M2) from the midnight shift. However, M2 was then assigned to work on another aircraft
and was instructed to verbally brief another midnight shift mechanic (M3) on the de-ice boot
replacement task. Then yet another mechanic (M4) was told to work on the de-ice boot replacement.
He was told to speak with a supervisor from the evening shift to nd out what work had been done.
Unfortunately, this mechanic (M4) approached the C-check supervisor from the evening shift,
who told him that he did not think that there would be sufcient time to change the left de-ice
boot that night.
Personnel on the midnight shift then proceeded to remove the leading edge assembly from the right
horizontal stabiliser, attach a new de-ice boot to it, and then re-install the right leading edge assembly
to the aircraft. The nal stages of the work were done outside in the dark, as the aircraft had been
pushed out of the hangar to make room for other work. None of the personnel involved noticed that
screws had been removed from the upper surface of the left horizontal stabiliser, and they would
have had no reason to suspect that the screws would have been missing.
Subsequently, the aircraft was cleared for ight. The rst ight of the morning passed without
incident, except that a passenger later recalled that vibrations had rattled his drink. He asked the ight
attendant if he could move to another seat. The passenger did not tell anyone about the vibrations,
and the other passengers did not notice them. The accident occurred on the next ight.
35
What handover procedures might have helped to avoid this accident?
Did problems with verbal communication contribute to the accident?
Have you ever observed any of these problems in your own workplace?
35
National Transportation Safety Board Aircraft Accident Report, NTSB/AAR-92/04 1992,
Continental Express Flight 2574, Embraer 120
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Effective and ineffective handovers
There are at least four types of maintenance shift handover, as shown in the diagrams below. In each case,
the handover is indicated by a vertical line. The rst shift is represented by the arrow on the left, and the
second shift by the arrow on the right. Shift handovers are often focused on the transfer of information from
one shift to the next, yet handovers also serve an important role as opportunities to catch and correct errors.
A healthy level of scepticism can help to ensure that the incoming shift reviews the work of the outgoing
shift, making as few assumptions as possible about its work.
Ideal handover. This is the ideal shift handover, where
the task is proceeding normally before the handover and
proceeds normally afterwards.
Error recovery handover. Although not ideal, this is also
an example of an effective handover. The task had gone
off track during the rst shift, but the handover provided
an opportunity to identify the problem and correct it.
An example is where an error made by the rst shift is
detected and corrected by the second shift.
Problem starts at handover. In this case, the task was
performed correctly by the rst shift; however, a problem
began when the second shift took over. An example is
a case where the rst shift removed a faulty component
for replacement. Instead of ordering and installing a
serviceable component, the second shift then re-installed
the faulty component.
Problem starts before handover. In this case, an error
was made on the rst shift, and personnel on the second
shift continued the error.
Four types of handovers
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Four ways to improve shift handovers
NASA researcher Dr Bonny Parke has studied what makes a successful handover, whether the setting
is a drilling rig, a maintenance hangar, or a hospital.
36
She has made the following recommendations to
improve handovers:
36
Parke, B., Patankar, K. & Kanki, B. (2003). Shift turnover related errors in ASRS reports. Proceedings of
the 12th International Symposium on Aviation Psychology, April 14-17, Dayton OH. (pp 918-923)
1

Use the handover as a chance to catch errors, not just communicate information
Critically check the work of the previous shift.
2

Improve shift handover documentation
In some cases there is a reluctance to produce written records beyond the minimum
requirements. However, temporary sources of information such as whiteboards can still
be an important source of task handover information.
3

Have direct verbal briengs between incoming and outgoing technicians
Face-to-face handovers are standard operating procedure in many high-risk industries
such as nuclear power, offshore oil and air trafc control.
4

Communicate next steps, not just work accomplished
A good handover not only covers the work that has been accomplished, but also captures
problems, possible solutions and future intentions.
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Tips for improving communication and avoiding
errors
When you are the sender
Provide information as required
Deliver information clearly and concisely
Verbalise planssurprises belong at birthday parties, not in hangars
Use appropriate non-verbal communication
Provide relevant information without being asked
Ask for conrmation that message is understood
When you are the receiver
Be an active listener
Acknowledge and repeat information as required
Paraphrase what you have heard
Pay attention to non-verbal as well as verbal communication
Clarify uncertainties, ask questions as necessary
Provide useful feedback
Both sender and receiver
Never assume
Dont let the conversation end with unresolved ambiguities
If a disagreement exists, take the most conservative action until more information is available
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Key points
Communication in maintenance involves not just words, whether written or spoken, but also
non-verbal cues (e.g. body language and tone of voice) and physical cues (e.g. the positioning
of tools and equipment).
Some of the most serious maintenance-related accidents have resulted from poor communication.
Communication can be surprisingly error-prone.
Pre-task briengs should be a routine feature of maintenance tasks. Make sure everyone understands
what the task will involve.
Poor shift handover threatens maintenance quality. Consider what you can do at your workplace
to prevent errors on tasks that extend over more than one shift.
When you are the sender of a message, make sure the receiver has understood it.
When you are the receiver, clarify the message and provide feedback to the sender. Be an active listener,
and paraphrase what you are hearing.
When you are ready, please turn to page 47 of the
Workbook for Engineers and complete the exercises.
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decision making
alcohol and other drugs
error management
teamwork
communication
leadership
fatigue
human performance
2013 Civil Aviation Safety Authority Australia